Provider Demographics
NPI:1386121101
Name:WALLACE, ARIANTE VANAE
Entity type:Individual
Prefix:
First Name:ARIANTE
Middle Name:VANAE
Last Name:WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MATHIES CIR
Mailing Address - Street 2:
Mailing Address - City:BARKSDALE AFB
Mailing Address - State:LA
Mailing Address - Zip Code:71110-2323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 MARSHALL ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4139
Practice Address - Country:US
Practice Address - Phone:318-226-9943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty